Provider Demographics
NPI:1740403088
Name:WINE, CHARLES JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JOSEPH
Last Name:WINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3117 HICKORY STICK RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-6001
Mailing Address - Country:US
Mailing Address - Phone:405-751-9274
Mailing Address - Fax:
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2512
Practice Address - Country:US
Practice Address - Phone:918-458-3360
Practice Address - Fax:918-458-3511
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9465207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKD35414Medicare UPIN
OK8HZ79XMedicare ID - Type UnspecifiedMEDICARE PROVIDER#